Clinical Judgement
A patient who just received a serious diagnosis reports a racing heart, sweating, and a feeling of impending doom. Which assessment should the nurse perform first before attributing the symptoms to anxiety?
What are the patient's airway, breathing, circulation, vital signs, and associated symptoms?
A nurse is teaching a pt who is newly prescribed Zoloft for OCD. The pt asks when they should expect to notice therapeutic effects?
It may take several weeks, sometimes 8-12 weeks or longer for OCD
A pt with OCD spends several minutes repeatedly checking that their front door is locked. Which symptom is the pt demonstrating?
compulsions
This type of psychotherapy helps pts identify negative thought patterns and replace them with more realistic, helpful ways of thinking.
A nurse is caring for a patient experiencing severe anxiety. The patient is pacing, trembling, and struggling to concentrate. Which nursing action is the priority?
What is staying with the patient and using short, simple statements in a calm voice?
A patient with OCD reports washing their hands 30x/day. The RN observes redness and skin cracking. What requires the nurse's attention?
Impaired skin integrity
A patient taking fluoxetine develops agitation, fever, sweating, diarrhea, and muscle rigidity after starting a new medication. What serious adverse reaction should the nurse suspect?
What is serotonin syndrome?
Rationale: Excessive serotonin activity, often caused by interacting serotonergic medications, can produce mental status changes, autonomic instability, and neuromuscular abnormalities.
A patient reports feeling nervous before an exam. The patient is alert, has slightly increased muscle tension, and can still concentrate and learn. Which level of anxiety is the patient most likely experiencing?
What is mild anxiety?
Rationale: Mild anxiety can increase alertness, motivation, and the ability to learn.
This therapy involves gradually exposing a pt to a feared situation while helping them develop healthier responses to anxiety.
A patient is experiencing panic-level anxiety. Pt is screaming, hyperventilating, and unable to follow instructions. What is the priority intervention?
What is maintaining safety and staying with the patient?
A patient under prolonged stress reports insomnia, poor appetite, and difficulty concentrating. Which additional finding requires the nurse’s most immediate follow-up?
A.The patient reports feeling overwhelmed at work
B.The patient says they have no energy for hobbies
C.The patient states they intend to end their life tonight
D.The patient reports occasional tension headaches
C. The patient states they intend to end their life tonight.
Rationale: Suicidal intent with a stated timeframe requires immediate safety assessment and intervention. Do not leave the patient alone while arranging urgent help.
The nurse receives reports on four patients taking medications for anxiety or OCD. Which patient requires the most immediate intervention?
A- a patient taking sertraline who reports mild nausea
B- a patient taking buspirone who reports mild dizziness.
C- a patient taking clonazepam who is difficult to awaken and has a RR of 8/min
Answer: C
Rationale:
Severe sedation with respiratory depression is the priority in this scenario.
A patient is pacing rapidly, trembling and unable to concentrate on the nurses questions. The patient says, "I cant think straight" and has difficulty following simple instructions.
What is severe anxiety
A pt experiencing anxiety practices slow breathing, progressive muscle relaxation and guided imagery to reduce physical tension.
What are relaxation techniques or coping skills
A pt with OCD has refused food for most of the day because they believe it is contaminated. Another pt is pacing and asking questions. Which pt should the nurse prioritize?
The patient is refusing food, determining the severity of the nutritional risk.
A patient experiencing a panic attack is hyperventilating, trembling, and reporting chest tightness. Which action should the nurse take first?
A.Ask the patient to identify childhood stressors
B.Assess airway, breathing, circulation, and vital signs
C.Tell the patient that the symptoms are harmless
D.Leave the patient alone in a quiet room
Correct answer: B. Assess airway, breathing, circulation, and vital signs.
Rationale: The nurse must assess for medical emergencies before assuming the symptoms are caused by panic. Stay with the patient and provide calm reassurance.
Nausea, diarrhea, sexual dysfunction and sleep changes
Side effects of SSRI's
Question 1: A patient reports feeling tense before a job interview. The patient has increased alertness, mild restlessness, and can still solve problems effectively. Which level of anxiety is most consistent with these findings?
A.Panic
B.Severe anxiety
C.Mild anxiety
D.Moderate anxiety
Correct answer: C. Mild anxiety may increase alertness and motivation while the patient remains able to learn, concentrate, and solve problems.
A patient with OCD understands that their checking rituals are excessive but cannot stop them. The rituals interfere with work and family life. Which treatment plan is most appropriate?
A.CBT incorporating exposure and response prevention, with medication evaluation as indicated
B.Punishment each time the patient checks a lock
C.Encouraging family members to perform all rituals for the patient
D.Avoiding discussion of symptoms and delaying treatment
Answer: A. Choosing an Intervention
ERP-based CBT is a first-line psychotherapy for OCD. SSRIs may also be prescribed, depending on symptom severity, patient preference, and clinical evaluation.
The nurse is caring for four patients. Which patient should the nurse assess first?
A. A patient with generalized anxiety disorder who reports difficulty sleeping.
B. A patient with OCD who is repeatedly arranging personal belongings.
C. A patient experiencing a panic attack who reports chest pain and shortness of breath.
D. A patient experiencing work-related stress who requests relaxation techniques.
Answer: C. What is the patient experiencing a panic attack with chest pain and shortness of breath?
Rationale: These symptoms may indicate a medical emergency and require immediate assessment. The nurse must rule out life-threatening causes rather than assume the symptoms are caused by panic.
A patient with OCD begins exposure and response prevention therapy. Which outcome best demonstrates improvement?
A.The patient reports never experiencing intrusive thoughts
B.The patient completes rituals whenever anxiety increases
C.The patient tolerates anxiety-provoking situations without performing the usual ritual
D.The patient asks family members to provide reassurance more frequently
Correct answer: C. The patient tolerates anxiety-provoking situations without performing the usual ritual.
Rationale: Exposure and response prevention helps patients face triggers and resist compulsions, gradually learning that anxiety can decrease without performing rituals.
A pt taking an SSRI also takes ibuprofen daily. What potential adverse effect should the nurse discuss?
What is increased bleeding risk
A patient reports months of chronic stress. Which cluster of manifestations most strongly suggests that stress is affecting multiple areas of functioning?
A.Occasional nervousness before public speaking
B.Persistent muscle tension, insomnia, irritability, GI upset, and impaired concentration
C.A brief increase in alertness before an exam
D.Repetitive handwashing only when hands are visibly dirty
Correct answer: B. Chronic stress may affect physical, emotional, and cognitive functioning, including sleep, muscle tension, digestion, mood, and concentration.
A nurse is working with a patient who experiences intense emotions and becomes overwhelmed during stressful situations. The patient often reacts impulsively and has difficulty regulating their emotions. Which DBT skill should the nurse encourage the patient to use when experiencing overwhelming emotions?
A.Avoiding the situation until the emotions disappear
B.Using distress tolerance skills to manage the crisis without acting impulsively
C.Suppressing emotions and refusing to discuss them
D.Relying on others to solve the problem
Correct answer: B. Using distress tolerance skills to manage the crisis without acting impulsively.
Rationale: DBT teaches patients mindfulness, emotion regulation, distress tolerance, and interpersonal effectiveness. Distress tolerance skills help patients cope with intense emotions safely without making the situation worse through impulsive actions.
A pt experiencing severe anxiety suddenly begins running towards the exit, shouting that they cannot escape. What should the nurse prioritize?
Maintain safety and use calm, verbal de-escalation